Diabetes Disaster Averted #13: Managing Weight-Loss Insulin Changes

I recently started working with a 58 y/o gentleman who had insulin dependent Type 2 diabetes. He was 110 pounds overweight, and was using 120 units of Lantus and 30 units of Humalog daily. His most recent A1c was 8.6....

The program he was placed on involved drinking a medical liquid food supplement 5 times a day which contains 12 grams of carbs per serving plus a meal that consisted of a small amount of protein and vegetables.

After speaking to the diabetes educator for the patient we agreed to cut his Lantus to 55 units daily and his Humalog to 1 unit per 4 grams of carbs and 1 unit per 12mg/dl with a target of 150.

The patient did very well for the first 4 days and glucose readings were much improved. However on the 5th day he started bottoming out with readings in the 50-70 mg/dl range. I called the diabetes educator as I was not sure what was going on.

The educator explained that my patient had severe insulin resistance and he was probably also suffering from glucotoxicity, and as his cells became depleted of glucose from the low carbohydrate plan he was on, he would be much more sensitive to the insulin and so if we did not decrease the insulin dosing he would probably continue go even lower. Working with the diabetes educator we were able to decrease his insulin and avert an accident or trip to the ER.

Many of our insulin using Type 2 patients will be starting on weight loss plans after the first of the year. In addition more patients will have lap-band procedures in 2011. These patients will have a significant decrease in the need for both basal and bolus insulin and it will be important that these patients know that if they start a diet or have the surgery, monitoring their glucose for lows will be required to avoid hypoglycemia, and we will need to adjust insulin doses down quickly and significantly. -- DJ

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